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Abstract

Background: Hysterosalpingography is a specialized radiological procedure that is used to assess tubal patency for female factor infertility evaluation. Patients who come for this procedure are understood to have anxiety. Aim: To determine the levels of patient anxiety that will be necessary for pre-counselling before exposure to hysterosalpingography. To examine the significant difference between the patients’ social demographic variables and levels of anxiety experienced. Patients/Methods: The study adopted a pre-test descriptive design to evaluate patient’s levels of anxiety with the state-trait anxiety scale. A total of 109 women undergoing hysterosalpingography were drawn through a convenience sampling technique. Results: The results shows that women waiting for exposure to HSG experienced high levels of anxiety with the (X=43.09 and SD=8.74). However, there was no significant difference between the patients’ social demographic variables measured and anxiety levels. Conclusion: extrapolating from these findings, there is the need for pre-counselling to relieve patient’s anxiety before hysterosalpingography.

Keywords

Patients; Anxiety; Hysterosalpingography; Tubal infertility

Introduction

The pressure of socio-cultural beliefs, values and tradition have
placed women in African societies on the precipice of joy and
sorrow regarding necessity of child bearing. This is largely
because of societal expectation of their role in reproduction.
As a result of this, any difficulty in childbirth is blamed on the
woman and this may lead to stigma, marital discord and divorce.
As a result of this, no woman wishes to think or feel that she is
infertile. [1] The thought of infertility creates a high current of
psychosocial conflict, loss of sense of worth, loss of honor and
dignity in matrimony. Indeed the desire to have a child is shared
by many couples around the world. This desire is an essential
factor influencing survival of human species. [1]

However, it is estimated that on the average, worldwide 10-15%
of couples have problem of infertility. The developed countries
are said to account for 10-15% and Sub-Saharan Africa 20-46%.
[2] In Nigeria, Panti and Sununu reported a prevalence of 15.7%
in North western part of the country. This problem is associated
with a great deal of stress, anxiety and financial burdens for
those families. [2] Nevertheless, the woman may be willing to
pay the price, make sacrifices and experience degradation of
exposure to screening of their genital tract by a health personnel.
She is ready to endure pains and discomfort associated with a
procedure like hysterosalpingography with the hope that the end
will justify the means.

Anxiety is typically characterized by feelings of fear, worry or apprehension. These are normal reactions to situations of
perceived stress. Anxiety can become a clinical concern when
the combination of stressful circumstances overwhelmed a
person’s ability and efforts to cope with those circumstances.
Studies have shown that hysterosalpingography is associated
with significant levels of anxiety. [3] Tyrrel and Hale reported
that a majority of patients knew why the examination was being
performed. Although only 50% had received an explanation
on the technique of the procedure prior to their arrival to the
department, anxiety levels associated with the examination were
high. This is not surprising, since high expectation, anticipation
of pains, curiosity about the outcome may bring with it intense
emotional distress. [3]

Inadvertently, anxiety precipitated by unpredictable report from
HSG brings about an additional cyclical problem. Agwu and
Okoye studied women undergoing a hysterosalpingography
procedure and 74% of those in the control group experienced
increased blood pressure while 64% experienced increased
heart rate. [4] Other studies have shown that Women who undergo
uncomfortable medical procedures experience some degree
of reactive anxiety. They are concerned with anticipated pain, embarrassment and discomfort. So, lack of knowledge of the
procedure and of any opportunity to establish control as well as
possible physical damage during the examination. The potential
diagnostic and prognostic implications are also contributory
factors for anxiety in this group of patients. [5]

Hysterosalpingography examines the state of the uterus and the
fallopian tubes to ascertain that the uterus and fallopian tubes has
normal shape and the cavity is not affected by disease process
such as; fibroids, polyps or scar tissue, tubal patency after tubal
surgery, congenital anomalies or other lesions in patients with
recurrent abortion etc. [6,7]

HSG involves the use of an image intensifier called a
Fluoroscopy and it is by means of this device that radiographic
films are obtained when a small amount of contrast is passed via
a cannula, filling the uterine cavity and then the Fallopian tubes.
Spillage into the peritoneal cavity and any abnormalities in the
uterine cavity or Fallopian tubes will be visible on a monitor.

There is paucity of data on the level of anxiety in patients’
undergoing HSG and to the best of our knowledge no study
of this nature has been done in our environment. It is against
this backdrop that the study seeks to determine the correlates of
anxiety levels among patients undergoing hysterosalpingography
assessment for tubal factor infertility in Makurdi.

The objectives of the study are:

• To determine the levels of patient anxiety that will be necessary
for pre-counselling before hysterosalpingography.

• To determine the significant difference between patients demographic
variables and levels of anxiety.

Hypotheses:

• Women who presents for hysterosalpingraphy will experience
considerable levels of anxiety.

• There will be significant difference between the patients’ socio-
demographic variables and levels of anxiety.

Methods

Research design

The study adopted a pre-test descriptive design. Each patient
booked for hysterosalpingography (HSG) procedure was asked
to complete a State-Trait Anxiety questionnaire lasting about 10
minutes. The pre-test was intended to elicit information which
can help to examine the participant’s anxiety level before going
into short session of the x-ray imaging (fluoroscopy).

Participants

A total of 109 adult females booked to receive HSG examinations
took part in this study at Musahafa Imaging Centre at Wadata,
Makurdi, Nigeria. The demographic characteristics of this
sample selected using the convenient sampling technique
include; marital status, parity, educational qualification, religion,
ethnicity and age. The primary criteria for eligibility were:

• Females booked for HSG examination.

• Being a married or unmarried woman.

• Having the willingness and acceptance to be a participant in
the study.

In view of the recognition of the ethical involvement in a research
of this nature, major ethical practice steps were taken to protect
the participant’s rights and reputation as they volunteered to be
used as sample in this study.

Firstly, each participant was briefed on the objectives and
significance of the study. Secondly, each participant’s consent
was obtained as she is convinced.

They were informed that their names and other means of identity
were not required and that the information provided will be treated
with confidentiality and strictly for the purpose of the study.

They were also told that they had a right to withdraw consent
prior and during the process of responding to the questionnaire.
The use and handling of instrument will terminate and be
destroyed after six months of successful completion of the study.

Instruments

The study adopted and used the State-Trait Anxiety Inventory
developed by Spielberger, et al. to collect data from the
participant. [8] The questionnaire is divided into two sections
with the first part consisting of demographic data of each
patient. The second part contains 20 self-descriptive statements
to which participants respond by noting the intensity of their
reactions which a person rates on a scale of anxiety (from not at
all 1, not much 2, much 3 and to 4 very much state of anxiety).
According to Spielberger et al, higher scores of current stress,
worrying, anxiety, and so forth represent greater state anxiety.
In this study, a Nigeria standardized version of scale was used.
[9-11] It was found to be cultural free with a reliability of 0.77 and
internal consistency as high as 0.98. [12] The established norms
for the Nigerian sample are presented in the Table 1 below.

Sex

STAI (X-1)

STAI (X-2)

Male
N=60

X=45.92
SD=7.37

46.67
SD=6.65

Female
N=60

X=39.7
SD=8.25

X=43.53
SD=8.83

Table 1: Means and standard deviation of test scores.

Procedure

The Nursing staff identified potential participants who met
all inclusion criteria. The investigator met with potential
participants, confirmed eligibility criteria. The participants
were given explanation regarding the nature of the study, aims
and objectives to obtain their consent. A consent letter was
assigned and each participant was given the States Trait Anxiety
Inventory (STAI-1) to complete.

Statistical analysis

Statistics was performed using the statistical package for social sciences SPSS version 16 Software. Data was critically analyzed
using the mean and standard deviation value to understand and
interpret the findings.

Results

A total of 109 females took part in the study, but in the course
of computation of data there was one observed missing system
that led to the presentation of the statistics result on 108
questionnaires. The ages of the participants ranged between
21 to 40 years with the mean of 32.09 (SD: 5.14). Ninety
two percent of the participants were married women while
eight were unmarried. The percentage distribution of their
demographic variables showed that 72 (67%) participants had
higher education, 36 (33%) had lower education. Amongst
those who were married, 77.2% had more than one child, while
22.8% did not have a child. The ethnic representation in the
study include: Tiv, Idoma, Igbo, Berom, Hausa, Igede, Yala, and
Obudu. Majority of these groups were Tiv (52%) and majority
of the study population were Christians (97.2%).

The result is presented in tabulation and interpreted objectively
in order to sustain the validity of the findings on the two
hypotheses [Table 2].

Variables

N

Minimum

Maximum

x̄

SD

Anxiety

108

29.00

114.00

88.07

14.97

State anxiety

108

11.00

64.00

43.09

8.74

Trait anxiety

108

13.00

64.00

44.98

8.22

Table 2: Analysis of the mean and standard deviation of patient’s anxiety levels and Hysterosalpingography.

The results on Table 1 shows that the State anxiety levels of
patients X̄ =43.09 and SD=8.74 imply that patients experienced
high level of anxiety before undergoing hysterosalpingography.

The Table 3 represents the means and standard deviations of
patient’s states and trait anxiety levels. With emphasis on state
anxiety scores, the findings shows that there is no significant
difference between these patients’ socio-demographic variables
and experience of high levels of anxiety before HSG.

Anxiety

State anxiety

Trait anxiety

Variables

N

x̄

SD

N

x̄

SD

Age

≥ 30
≤ 30

70

43.40

8.82

70

45.42

7.70

37

42.40

8.76

37

44.32

9.22

Marital status
Single
Married

8

45.50

9.08

8

43.87

1.83

99

42.84

8.76

99

45.23

0.83

Parity
1 child
No child

21

44.95

8.92

21

45.90

7.52

71

42.60

8.42

71

45033

8.16

Religion*
Christians

94

43.86

8.28

94

45.72

7.34

Islam

3

39.33

7.76

3

37.66

8.50

Education
High
Low

73

43.93

8.42

72

45.47

7.81

36

42.57

7.21

26

45.76

6.85

Table 3: Analysis of the means and standard deviation of patients’ levels of anxiety and HSG on five socio-demographic variables.

Discussion

The purpose of the study was to investigate Correlates of anxiety
levels among patients undergoing hysterosalpingography
assessment for tubal infertility in Makurdi. In analysing the data
and observing the means and standard deviation of state anxiety
and trait anxiety it was found that patients who present for HSG
experience significant higher levels of anxiety (P< 0.05). This
was premised on the fact that the level of state anxiety which
was (X̄ =43.09, SD=8.74) and trait anxiety (X̄ =44.98, SD=8.22)
scores were higher than those reported (X̄ =39.7, SD=8.25) score
derived from a sample of 60 Nigerian women for restandardized
version of scale. [9-11] This has indicated a state of anxiety among
women awaiting radiological examinations.

The second hypothesis which states that there will be significant
difference in the variation of socio- demographic variables and
patients’ levels of anxiety was rejected. This was confirmed
from the test scores of the mean and standard deviation on state
anxiety of the patients’ measured socio-demographic variables
[Table 2]. Psychologically, anxiety is typically triggered by a
combination of different degrees of stressors and the ability of
the patient to react to the stressor is largely dependent on his or
her positive or negative interpretation of their stimulus effect. By
virtue of the findings of hypotheses 1 and 2, this study supports
the report of previous studies that HSG is associated with high
levels of anxiety. These findings were situated on observation
that some of the participants awaiting HSG may have little
knowledge and experience of the procedure. Yet, to some it
may be due to a persistent negative feelings and thoughts that
the outcome of HSG investigation will not be favorable. These
views are consistent with those of Tyrel et al. [3]

Furthermore, the current findings supported the report of Agwu
and Okoye whose study showed that women who are to undergo
hysterosalpingography procedure had elevated blood pressure
in 74% of those in the control group, while 64% experienced
increased heart rate. [4] Similarly, a study by Aksoy et al.
reported that radiological procedure of invasiveness positively
and strongly predicts increase level of anxiety in women. [5]

Notwithstanding the similarity of the results of five demographic
variables measured such as marital status, educational
background, parity and religion, in this study compared with
other study, there was an observed variation of the findings
regarding the women’s age with findings of Aksoy et al. [5] The
factor of age which was positively correlated with experience
of anxiety could not be confirmed. In this study, the findings
show no significant difference between the patients’ age and
experience of anxiety before HSG. With reference to Table 2 the
state anxiety scores of (X̄ =43.40 and SD=8.82) of women above
30 years and the state anxiety scores (X̄ =42.40, SD=8.76) of women less than 30 years imply that the age of women presenting
for HSG does not show any statistical difference. In addition,
findings on demographic variables such as level of education,
cultural background, parity and religion were not found to be
associated with the patients’ experience of high levels of anxiety.
This suggests that there could be other spurious factors that are
responsible for the increased levels of anxiety in the women.
These may include the woman’s higher expectation, anticipated
pains, worry and apprehension regarding negative feelings and
thought that HSG as an investigative procedure on the integrity
of the status of the tubes may not show a favorable outcome.
This perceived unfavorable outcome is often interpreted by
the women as a threat to their fertility status and inability to
conceive in their life time. These thoughts and feelings are
capable of inducing anxiety and depression. [13]

Furthermore, the woman’s concerned with anticipated pain,
embarrassment and discomfort from the invasion of her private
organ by the opposite sex other than the spouse or a suitor, lack of
knowledge of the procedure and of any opportunity to establish
control, possible physical damage during the examination, and
potential diagnostic and prognostic implications cumulatively
precipitate anxiety as found in several similar studies. [5]

Conclusion

The study shows that women presenting for HSG have some
level of anxiety. Hence, pre counseling and education should
be done to relief or help patients understand the nitty-gritty of
the HSG test, advantages and disadvantages so as to relief their
anxiety.

This study did not assess the patient’s vital signs before or after
the administration of the anxiety scales to correlates the result of
the statistical findings on the presence of anxiety amongst these
women. Yet it is hoped that through a broader understanding
of the precipitating factors of anxiety reactions before HSG,
it is pertinent to address the patient’s worries and fears before
this particular procedure is carried out. Therefore, physicians,
radiologists and nurses technicians should be prepared to manage their clients by interviewing them to obtain useful
information to provide expert support for these patients.